Preventive Interventions: An Immediate Priority

In 2006 I recommended people use what was then the just-published ranking of the most valuable clinical preventive services to inform decision making with the aim of improving population health.¹ In the intervening decade much has changed in the health care sector. The Patient Protection and Affordable Care Act (ACA) has significantly increased access to primary care to previously uninsured Americans and includes provisions to increase the delivery of clinical preventive services, although these advances may be in jeopardy. In addition, there has been a marked evolution from a fee-for-service health care reimbursement system to a pay-for-value paradigm. In the past 10 years, however, some things have not changed, and the opportunity and need to use a systematic, rational approach to prioritize the delivery of evidence-based health care services has only grown.

In 2008, then-Senator Barack Obama, writing in the Journal of the American Medical Association (JAMA), touted that his health care plan would “ensure that Americans have access to preventive care.”² After his election as president, he made good on that promise, ultimately signing into law the ACA, which included provisions to reform the health insurance sector, to expand health insurance coverage for millions, and to provide for no-cost out-of-pocket preventive services coverage. In July 2016, President Barack Obama wrote, again in JAMA, that “early evidence indicates that expanded coverage is improving access to treatment, financial security and health for the newly insured.”³ The President cited the growing role of alternative payment models focused on outcomes and described how nearly 30% of Medicare payments are now flowing through models that push the emphasis beyond an individual service. As a result of these changes, the updated ranking of clinical preventive services may be an essential point of reference for decision making and prioritization in this changing environment.

As a part of its ongoing work to periodically update the clinical preventive services ranking, the National Commission on Prevention Priorities in this issue of the Annals of Family Medicine releases the 2016 updated list of priorities after examining 28 services with strong evidence of effectiveness.⁴ This ranking stratifies services based on population-wide health impact and cost-effectiveness.

In one sense, the update provides a reassurance that the value (health impact and cost effectiveness) of prevention remains consistent, and priorities need not undergo tectonic shifts. Tobacco use counseling and childhood vaccinations, for example, continue to be top ranked. Two behavioral health screenings are included in the ranking: screening for alcohol misuse is an expected cost-saving service; screening for depression ranks lower, but depression screening scores the same as breast cancer screening and the provision of the pneumonia vaccine in adults. Yet an analysis of actual utilization, provision of services, uptake of services, and how many more years of healthy life individuals could gain with those services shows a wide gap between what we know should be done and what we actually do in health care.⁴ Some groups, people of color, for example, often have even greater gaps than the general population. Eliminating those gaps in delivery of high-ranking services should be a high priority. Improvements in coverage, affordability, and incentives that have occurred in the last several years suggest that we should be held even more accountable to do better optimizing America’s health.

There is opportunity to do better. Combining the science of prevention with the comparative value of the ranking creates the mechanism to systematically and rationally improve on delivering preventive services and realizing health effects in a sequenced manner that optimizes resource utilization. Peoples’ lives are adversely affected by the degree to which we are not delivering preventive services well. Cost-saving preventive interventions should be a clear, immediate, or first-action priority. There is no good reason why cost-neutral interventions cannot reach 100% utilization. Cost-saving and cost-neutral preventive service delivery makes good sense in a resource-constrained or time-constrained environment. Smart preventive service delivery makes sense in an accountable care environment.

The publication of the 2016 ranking occurs at a pivotal time in our history: a changing health and health care landscape with opportunity and challenges, both. It has never been more important to apply a rational approach to safeguarding good health by translating science into good practice. The ranking of clinical preventive services is an invaluable translational guide to deliver recommended quality services, improve the health of individuals, eliminate health disparities, and use resources responsibly.